No.

:
For College use only Batch No.
S.E. / T.E. / B.E. Sr. No.

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NORTH MAHARASHTRA UNIVERSITY, JALGAON
Second / Third / Fourth Year in Engineering Examination Form

To,
No. of
The Controller of Examinations, Subjects
North Maharashtra University, Jalgaon – 425 001.

Respected Sir, Exam. Fee Rs.-------------

I request permission to present myself for the S.E. / T.E. / B.E. / Examination in Convocation Fee Rs._____
Statement of
Engineering ____________________________________ to be held in April / May / Oct. /
Marks Fee: Rs.---------
(Please write name of the Branch)
CAP Fee : Rs.--------
Nov., 20 and pay herewith the prescribed fee Rs.-------------.
Late Fee : Rs.---------
Total Fee : Rs.--------
Date : / / 20 Signature of the Candidate

Branch Name ( Tick
on appropriate Branch )

Civil Mech Prod. Elex. Instru. Electrical Computer E&TC Chemical I.Elex Auto I.T. E&C
11 12 13 14 15 16 17 18 19 20 21 22 23

1. * NSS NCC NPED AED TOURNAMENTS Not 2. SC ST OBC DT NT SBC Not

IU N IN Applicable Applicable
1 2 3 4 5 6 7 8 C T O D N S
1 2 3 4 5 6 7
3. Sex : Male Female 4. FRESH REPEATER
1 2 1 2

5. College Code : Centre Code:

6. Write full name in legible CAPITAL letters.

Surname Name Father’s/Husband’s Name

7. Name in Devnagari script
( Students are requested to write their names as appeared in the previous qualifying statement of Marks)

8. Address for Correspondence :

9. Permanent Registration Number (PRN) if applicable :

10. No. of Course appearing **

11. S.E. / T.E. / B.E. Sem. Combinat ion Term–I Term-II Term-I & II (Pl. tick)

12. Latest appearance at S.E./T.E./ B.E. May, 05 Nov., 11 Year

details if applicable (Pl. tick) Month Seat No.

13. Latest appearance at S.E. / T.E. / B.E. May, 05 Nov., 11 Year

details if applicable (Pl. tick) Month Seat No.

* The Students who has participated in any of the extra – curricular activity should fill in the prescribed form for this purpose.
** Paper/Practical/Term Work/Oral each is considered as separate course.

(P.T.O.)
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S.E./T,E./B.E. ( Course_____________ ) Branch : ___________________ Branch Code : _____

No. Subject Paper Term Work Practical Oral

1 2 3 4
TERM – I Code Code Code Code
1.
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2.
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5.
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6.
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7.
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8.
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TERM – II
1.
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2.
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3.
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4.
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5.
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6.
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7.
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8.
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NOTE : 1. Tick
in appropriate box as per syllabus.

2. The concerned college should write S ubject Code in the place where line is provided in
Col. No. 1 to 4.
3. The year of starting of Syllabus is to be mentioned against Course.
4. Write Branch Name and Code No. in the place provided in the format.
5. Subject names & codes are available on University Website http : // www. nmu. ac.in

Certificate to be signed by the Principal of the College of Engineering

at which the Candidate has studied

I Certify that Shri/Smt.

1) has attended adequate number of lectures required as per rules.

2) has co mpleted to my sat isfaction the prescribed Practical Work including Laboratory Work, Term
Work etc. in the subjects concerned.
3) is, to the best of my knowledge and belief, a person o f good conduct and has my permission to
appear at the ensuing Third Examinat ion in Engineering.
I also certify that his/her statement having passed in the Papers and / or Practicals, Term Work, Oral, etc.
indicated above at the previous Examinat ions, is correct.

Place : Signature :

Date : Principal : College

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